Background: Evidence on the learning curve for robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is limited.Objective: To assess the effect of surgical... Show moreBackground: Evidence on the learning curve for robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) is limited.Objective: To assess the effect of surgical experience (SE) on perioperative and intermediate-term oncological outcomes in a large contemporary cohort of RARC patients after accounting for the impact of intersurgeon variability.Design, setting, and participants: The study cohort included 164 patients treated with RARC and ICUD by two surgeons between 2004 and 2017 at a single European referral centre.Outcome measurements and statistical analysis: For each patient, SE was defined as the total number of RARCs performed by each surgeon before the patient's operation. The relationship between SE and operative time (OT), lymph node yield (LNY), positive surgical margins (PSMs), Clavien-Dindo grade >= 2 30-d postoperative complication (CD >= 2), and oncological outcomes (18-mo recurrence rate) was evaluated in multivariable linear and logistic regression models, clustering at a single-surgeon level.Results and limitations: After adjusting for case mix, SE was associated with shorter OT (p = 0.003), lower probability of postoperative CD >= 2 rates (p = 0.01), and lower 18-mo recurrence rates (p = 0.002). Conversely, SE did not predict lower PSM rates (p = 0.3) and higher LNY (p = 0.4). The relationship between SE and OT was nonlinear, with a plateau observed after 50 cases. Conversely, the relationship between SE and CD >= 2 and 18-mo recurrence was linear without reaching a plateau after 88 procedures.Conclusions: SE affects perioperative and oncological outcomes after RARC with ICUD in a linear fashion, and its beneficial effect does not reach a plateau. Conversely, after 50 cases, no further improvement was observed for OT.Patient summary: Robot-assisted radical cystectomy with intracorporeal urinary diversion is a complex surgical procedure with a relatively long learning curve. (C) 2020 European Association of Urology. Published by Elsevier B.V. All rights reserved. Show less
Purpose: Radical cystectomy currently is the treatment of choice in muscle-invasive bladder cancer. However, cystectomy is associated with considerable morbidity. Bladder sparing treatment consists... Show morePurpose: Radical cystectomy currently is the treatment of choice in muscle-invasive bladder cancer. However, cystectomy is associated with considerable morbidity. Bladder sparing treatment consists of transurethral resection of the tumor (with or without partial cystectomy), external beam radiotherapy, and brachytherapy. The purpose of this study is to compare bladder preservation with brachytherapy to cystectomy by a systematic review.Material and methods: A systematic review was conducted using PubMed electronic database. Article selection was done independently by two authors. Data were extracted on cause-specific survival and overall survival at 2, 5, and 10 years. Comparison of the two treatment modalities was done by a Weibull survival analysis with metaregression analysis and estimation of Hazard Ratio's (HR's) with 95% confidence intervals (CI).Results: Large differences in tumor staging and tumor grading were found between cystectomy and bladder sparing series. The adjusted HR's for cause-specific survival and overall survival were 1.27 (95% CI: 1.15-1.40) and 0.85 (95% CI: 0.84-0.87), respectively for bladder sparing relative to radical cystectomy.Conclusions: Robustness of the analysis is hampered by the retrospective character of the study and differences in patient characteristics. For selected cases, bladder sparing by brachytherapy leads to at least similar overall survival compared to radical cystectomy for muscle invasive bladder cancer. Show less
